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The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/122/6/1387.full.html
POLICY STATEMENT
ABSTRACT
This policy is a compilation of current concepts and scientific evidence required to
understand and implement practice-based preventive oral health programs designed to improve oral health outcomes for all children and especially children at
significant risk of dental decay. In addition, it reviews cariology and caries risk
assessment and defines, through available evidence, appropriate recommendations for preventive oral health intervention by primary care pediatric practitioners. Pediatrics 2008;122:13871394
www.pediatrics.org/cgi/doi/10.1542/
peds.2008-2577
doi:10.1542/peds.2008-2577
All policy statements from the American
Academy of Pediatrics automatically expire
5 years after publication unless reafrmed,
revised, or retired at or before that time.
Key Words
pediatric oral health prevention, oral health
intervention
PURPOSE/INTRODUCTION
Abbreviation
PATFprofessionally applied topical
uoride
1387
produced by bacterial fermentation of carbohydrates reduce the pH of dental plaque to the point at which
demineralization of the enamel occurs. The initial carious lesion appears as an opaque white spot on the
enamel, and progressive demineralization results in cavitations of the teeth. Dental caries is a process, and loss of
tooth structure (a dental cavity) is an end stage in the
process.7
Human dental flora, generally regarded as qualitatively stable once established and site specific to human
dentition, is believed to consist of more than 1000 different organisms, of which only a limited number are
associated with dental caries.8 Streptococcus mutans is most
strongly associated with dental caries and is considered
to be an indicator organism of a subpopulation of cariogenic organisms. S mutans, like its related cariogenic
cohorts, has the ability to adhere to enamel and is
uniquely equipped to produce significant amounts of
acid (acidogenic) and endure within that acidic environment (aciduric).
Dental flora adheres to the teeth by creating a tenacious and highly complex biofilm referred to as dental
plaque. Dental plaque is capable of concentrating dietary
sugars; therefore, the chronic consumption of sugary
foods and liquids will continually recharge the plaque
matrix, resulting in copious supplies of sugars within the
plaque matrix. S mutans and other cariogenic flora will
then ferment available sugars, resulting in high levels of
lactic acid, a decreased local pH (5.0), and demineralization of dental enamel (at an approximate pH of 5.5).
Because S mutans and its aciduric cohorts continue to
thrive at low pH, the resulting environment selects
against nonaciduric flora, creating a shift in the subpopulation ratio of benign to aciduric flora. As this process continues over multiple generations, aciduric organisms incur an upregulation of virulence genes that
allow them to thrive at even lower pH (4.0). Diet-mediated shifts in subpopulation ratios of dental flora are
instigated by significant sugar intake (environmentally
selecting for carious organisms). Therefore, significant
sugar intake is a driving cause of the caries process.
Preventive Strategies
An understanding of normal dental flora serves as a
foundation for the development of preventive strategies,
with 2 important considerations. First, dental flora exists
in a symbiosis with the human species. Second, only a
small number of the organisms within dental flora cause
caries. Therefore, our objective is not to eliminate all
dental flora but to suppress the cariogenic bacteria
within the flora.
Preventive strategies can be differentiated into 2 distinct categories. Primary prevention involves optimization of maternal dental flora before and during colonization of the oral flora of the infant (during eruption of
the primary dentition). This invaluable mode of prevention provides an opportunity for a reduction in the
mothers constitutionally virulent, aciduric flora and
downregulation of virulence genes within the aciduric
flora, decreasing the childs risk of dental decay, and is
the basis for first dental visit recommendations at 1 year
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or earlier made by various medical and dental organizations. This mode of prevention and its adjuncts are reviewed in detail in a policy statement from the American
Academy of Pediatrics, Oral Health Risk Assessment
Timing and Establishment of the Dental Home.9
Secondary prevention is the continual and ongoing
management of subpopulation ratios of benign and aciduric flora within dental plaque. This mode of prevention consists of managing the balance between causative
factors and protective factors and is critical for preventing and reversing the caries process. Secondary preventive strategies are hierarchical and currently consist of
dietary counseling, oral hygiene instruction, and judicious administration of fluoride modalities. Therefore,
although all preventive modalities are important, modification of diet is most important, followed by oral hygiene compliance and then administration of fluorides.
By controlling risk factors before disease occurs, the
probability of preventing disease, both in the immediate
future and the long-term, is improved. Preventive strategies for this complex, chronic disease require a comprehensive and multifocal approach that begins with caries
risk assessment.
Caries Risk Assessment
Caries risk assessment, based on developmental, biological, behavioral, and environmental factors, evaluates
the probability of enamel demineralization exceeding
enamel remineralization over time. The goal of risk assessment is to anticipate and prevent caries initiation
before the first sign of disease. During the period of
1999 2002, 41% of US children 2 to 11 years of age had
caries in primary teeth.2 An earlier study noted that 25%
of children 5 to 17 years of age had 80% of carious
permanent teeth.10 Assessing each childs risk of caries
and tailoring preventive strategies to specific risk factors
are necessary for improving oral health in a cost-effective manner.
Caries risk assessment is very much a work in
progress. In a systematic review of literature regarding
risk factors in primary teeth of children aged 6 years and
younger, a paucity of studies of optimal (ie, longitudinal)
design was noted.11 A study that evaluated the reliability
of multiple risk indicators determined that there is no
consistent combination of risk variables that provide a
good predictor of caries risk when applied to different
populations across different age groups.12 The authors
concluded that the best predictor of caries in primary
teeth was previous caries experience, followed by parents education and socioeconomic status.12 Although
previous caries experience cannot be used as a risk indicator for the predentate or very young child, whitespot lesions, as precursors to cavities, can be considered
analogous to previous caries experience when assessing
the risk of a very young patient. An analysis of National
Health and Nutrition Examination Survey (NHANES) III
data revealed that children from households with low
income levels are more likely to experience caries and
have higher levels of untreated caries than their counterparts from higher-income households.13 Collectively,
children enrolled in Special Supplemental Nutrition Pro-
gram for Women, Infants, and Children (WIC) programs, Head Start, or Medicaid are at higher risk than
are children in the general population.
Caries risk factors unique to infants and young children include perinatal considerations, establishment of
oral flora and host-defense systems, susceptibility of
newly erupted teeth, dietary transitioning from breast
and bottle feedings to cups and solid foods, and establishment of childhood food preferences. Although preterm birth per se is not a risk factor, a child with low
birth weight may require a special diet or have developmental enamel defects or disabilities that increase caries
risk. Early acquisition of S mutans is a major risk factor
for early childhood caries and future caries experience.14
A reduction of the salivary level of S mutans in highly
infected mothers can inhibit or delay colonization of
their infants.15 Although evidence suggests that children
are most likely to develop caries if S mutans is acquired at
an early age, this may be compensated in part by other
factors such as good oral hygiene and a noncariogenic
diet.11 High-risk dietary practices seem to be established
early, probably by 12 months of age, and are maintained
throughout early childhood.16 In addition to the amount
of sugar consumed, frequency of intake is important.17
Sugar consumption likely is a more significant factor for
those without regular exposure to fluorides.18 Children
experiencing caries as infants and toddlers have a much
greater probability of subsequent caries in both the primary and permanent dentitions.19
Early risk assessment targets infants and young children who traditionally have yet to establish a dental
home. Unrecognized disease and delayed care can result
in exacerbated problems, leading to more extensive,
costly, and time-consuming care.
Risk-assessment strategies most applicable for screening purposes include those that are acceptable to patients, reliable, inexpensive, and performed easily and
efficiently and require limited equipment/supplies. The
American Academy of Pediatric Dentistry (AAPD) has
developed a caries risk-assessment tool for use by dentists and primary care practitioners familiar with the
clinical presentation of caries and factors related to caries
initiation and progression (see www.aapd.org/media/
PoliciesGuidelines/PCariesRiskAssess.pdf).20 Radiographic assessment and microbiologic testing have been
included in the caries risk-assessment tool but are not
required. In addition, the American Academy of Pediatrics has created Oral Health Risk Assessment Training for
Pediatricians and Other Child Health Professionals, which
provides a concise overview of the elements of risk assessment and triage for infants and young children (see
www.aap.org/commpeds/dochs/oralhealth/screening.
cfm).21
The chronic, complex nature of caries requires that
risk be reassessed periodically to detect changes in the
childs behavioral, environmental, and general health
conditions. All available data must be analyzed to determine the patients caries risk profile. Periodic reassessment allows the practitioner to individualize preventive
programs and optimize the frequency of recall and dental radiographic examinations.
tween meals.
Encourage children to eat fruits.
Limit the intake of 100% fruit juice to no more than 4
oz per day.
Foster eating patterns that are consistent with My-
1389
preventive pediatrics. Information concerning the impact of diet on dental health and counseling in regards to
oral hygiene, nonnutritive oral habits, and dental safety
should be shared with parents. Therefore, in addition to
dietary counseling and optimizing fluoride exposure, anticipatory guidance for oral health includes:
1. Infant oral hygiene instruction: Teeth should be
brushed at least twice daily with caregiver supervision and assistance for children. For children with
elevated dental caries risk, consider using a pea-sized
amount of toothpaste or an amount equivalent to the
childs fifth-digit fingernail. Flossing should begin as
soon as adjacent teeth are in contact and for surfaces
at which 2 teeth touch and they can no longer be
cleansed with a toothbrush.
2. Counseling regarding nonnutritive oral habits: Use of
pacifiers in the first year of life may prevent sudden
infant death syndrome.56 Sucking habits (eg, pacifiers
or digits) of sufficient frequency, duration, and intensity may be associated with dentoalveolar deformations. Some changes persist past cessation of the
habit. Professional evaluation is indicated for nonnutritive sucking habits that continue beyond 3 years of
age.53
3. Age-appropriate information regarding dental injury
prevention: Parents should cover sharp corners of
household furnishings at the level of walking toddlers, ensure use of car safety seats, and be aware of
electrical cord risk for mouth injury. Properly fitted
mouth guards are indicated for youths involved in
sporting activities that carry a risk of orofacial injury.
Anticipatory guidance is valuable, because it emphasizes
prevention of dental problems rather than surgical or
restorative care. Anticipatory guidance and well-child
visits during the first 2 years of life decrease the number
of hospitalizations among poor and near-poor children
irrespective of race and health status.57 Oral health anticipatory guidance can reduce dental expenditures.58 In
light of this evidence, oral health anticipatory guidance
should be integrated as a part of comprehensive counseling during well-child visits.59
INTERPROFESSIONAL COLLABORATION AND
ESTABLISHMENT OF A DENTAL HOME
To be successful in preventing dental disease, interventions must begin within the first year of life. Pediatricians
are well positioned to initiate preventive oral health care
by providing early assessment of risk, anticipatory guidance, and timely referral to establish a dental home. The
American Academy of Pediatric Dentistry, the American
Dental Association, and the American Association of
Public Health Dentistry recommend that infants be
scheduled for an initial oral examination within 6
months of the eruption of the first primary tooth but by
no later than 12 months of age.
The pediatric community promotes the concept of a
medical home to improve families care utilization, seeking appropriate and preventive services with optimal
compliance to recommendations. The concept of the
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CONTRIBUTORS
STAFF
High Caries Risk Protocol:
Dietary and Hygiene Counseling,
Fluoride Varnish at 1-y
Intervals Until Establishment of
a Dental Home
FIGURE 1
Pediatric medicine: oral health intervention algorithm.
FIGURE 2
High caries risk protocol.
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